What is Prolotherapy?

Sclerosant Injections to Ligaments

Ligaments help to provide stability to joints. They prevent the joint from moving more than the 'normal range' (though what is 'normal' varies from one individual to another). Some people have lax ligaments that allow greater than 'normal' movement in the spine and elsewhere. After the treatment of prolapsed discs or chronic back pain, instability may be a significant cause of recurrent problems. The use of Prolotherapy reduces the risk of recurrence and helps people return to activities faster.

In the spine there is a complex arrangement of ligaments, both between each vertebral segment and between the spine and pelvis, which allows flexibility in some directions and produces restraint in others.

Sometimes ligaments can be overstretched, or even torn (as in a sprained ankle). The ligament may then not control the joint adequately – thus leading to 'instability' which may put abnormal stresses on the joints and discs in the spine.

In women, the pelvic joints need to be supple for child bearing, and so the ligaments soften and stretch more readily. Sometimes they do not tighten up after childbirth and therefore allow too much movement – hence 'sacroiliac instability'.

Prolotherapy works by stimulating the body to make new fibres which are laid down within the substance of the ligaments, thickening and strengthening them. The solution is a 25% mixture of dextrose in local anaesthetic, and a small amount is injected into each end of the ligament, close to its attachment to the bone. We occasionally use a solution of phenol dextrose + glycerol if required. This initially provokes inflammation, attracting the cells that make collagen fibres to the area. Over the ensuing weeks, the fibres are incorporated into the existing ligament. Each ligament has to be injected three times, at intervals of a week, in order to produce sound fibrous development. Hence three injections are given as a course of treatment. The interval can be up to three weeks.

As Prolotherapy for ligaments is not widely practised, it has not as yet been licensed for this particular type of treatment. Our 50% glucose ampoules are provided by a licensed manufacturer, as are the ampoules of P2G that is occasionally used in difficult cases. Because the organic compounds in the solution are rapidly disposed of by the body, it is safe to have a repeat course of treatment – should it be necessary.

There have been several widely published clinical trials on its usefulness in low back pain with positive results. Prolotherapy does not create scar tissue but thicker healthy collagen fibres in the lax ligaments. Injections are commonly given in the lumbar region, sacroiliac region, thoracic and cervical spine. They are also useful in the ankle and shoulder region.

Neural Prolotherapy
Neural Prolotherapy is a more recently developed concept for the treatment of painful conditions along with joint, tendon, ligament and muscle pain. The treatment involves a series of injections with a glucose solution, immediately under the skin with a very fine needle, targeting the source of the pain. It can offer a success rate of greater than 75%.

Neural Prolotherapy was developed by Dr. John Lyfgodt MRNZCGP in New Zealand. His research focused on the treatment of Achilles tendon pain with an apparent success rate of more than 90%. He has published two level 4 articles on Achilles tendon pain. The treatment of the Achilles tendon is different from the more usual Prolotherapy in that the injections are given just under the skin.

A less invasive treatment than Prolotherapy, Neural Prolotherapy has been successfully used in the treatment of tennis elbow, painful knees, shoulders, neck, hips, ankles, muscle injuries and low back pain. Results are consistent and two year follow-up studies have shown success rates between 80-100%.

How does it work?
Neural Prolotherapy does not target tendons, ligaments or joints. An hypothesis was developed that glucose assists in the repair of connective tissue in the nerve trunks under the skin similar to the way repair of connective tissue in ligaments and tendons is effected by the more usual type of Prolotherapy. These skin nerves are now known to be responsible for painful conditions known as neuralgia or neuropathic pain. They consist of up to 80% connective tissue and are structurally quite similar to tendons and ligaments.

There is now scientific evidence that the very small nerves innervating the nerve trunk, known as nervi nervorum are responsible for inflammation of the connective tissue of the nerve trunk and surrounding tissues. It is also known that this neurogenic inflammation differs from conventional inflammation in that it does not respond to anti-inflammatories or cortisone injections. It is clear from clinical observations on more than three thousand patients and large case series that Neural Prolotherapy effectively reverses neurogenic inflammation and resolves neuralgia pain.

Course of Treatment
Treatment typically involves 3-6 sessions of small injections, just under the skin with a very small needle. Additional sessions are occasionally needed. Treatments last a few minutes. At most the patient may have a small amount of tenderness at the injection site. Physical activity is not restricted post-injection, with most patients returning to their usual workouts the same day or next day. More than 98% of patients tolerate the minimal discomfort associated with the injections without a problem.

History of Prolotherapy
Prolotherapy was developed in the 1940s by Dr George Hackett, using injections of a sclerosing agent commonly used at the time for varicose veins. He targeted ‘lax’ or ‘weak’ ligaments with these injections to make them stronger.

Hackett believed that if ‘weak’ ligaments were the cause of most joint and ligament pain, strengthening them would resolve the pain. He published 16 articles and a textbook on this procedure, and claimed an 80% success rate for the treatment of low back pain as well as many other painful conditions. A growing number of Prolotherapy studies over the last 40 years have indicated good to excellent results from this type of treatment, with doctors in the UK, USA, Australia and elsewhere continuing to use glucose injections (now using more advanced glucose solutions) with no side effects for painful conditions affecting joints, ligaments and tendons.

Evidence-based medicine has become a popular pre-requisite for medical providers in the last 20 years. But scientific research has become out of the financial reach of most researchers, unless they are supported by large grants or the Pharmaceutical industry. As a result, it has been difficult to find good high-level evidence research on Prolotherapy.

Three researchers, Professor Michael Yelland from Australia and Professors David Rabago and K. Dean Reeves from the USA, have produced some excellent studies published recently, including a randomised control trial for treatment of Achilles tendinosis (British Journal of Sports Medicine, 2009). Dr John Lyftogt has also published six level 4 studies in the Australasian Journal of Musculoskeletal Medicine since 2005.